2. ACLS
• Systematic approach to assessment and
management of cardiopulmonary emergencies
• Continuation of Basic Life Support
• Resuscitation efforts aimed at restoring
spontaneous circulation and retaining intact
neurologic function
ABCD
2
3. Adult
Chain of
Survival
• Immediate recognition of cardiac arrest and
activation of the emergency response system
• Early CPR with emphasis on chest compressions
• Rapid Defibrillation
• Effective advanced life support
• Integrated post cardiac arrest care
04JUL2013 ACLS-BMS 3
6. The
AAA’s
of ACLS
• Assess the patient
– Establish unresponsiveness
– Check pulse, respirations
• Activate EMS
– Call for help
• AED
– Get an AED (automated
external defibrillator)
6
8. Airway
• Open the airway
– Head tilt-chin lift
– Jaw thrust
Wellcome Photo Library, Wellcome Photos
Wellcome Photo Library, Wellcome Photos
8
9. Breathing
• Look, Listen and Feel
• Give 2 rescue breaths
• Watch for appropriate chest rise and fall
U.S. Navy photo by Photographer's Mate 3rd Class Jesse Praino, Wikimedia Commons
9
10. Circulation
U.S. Navy photo by Mass Communication Specialist Seaman Gabriel S. Weber, Wikimedia Commons
10
Check for a pulse
Start CPR
• 30 compressions/
• 2 respirations
Compressions more
important than respirations!
11. High
Quality
CPR
• Start compressions within 10 sec of
recognition of cardiac arrest
• Push Hard, Push Fast : atleast 100/min,
• atleast
2” or 5cms depth
• Allow complete chest recoil after each
compression
• Minimize interruptions in compressions
to < 10sec
• Give effective breaths (visible chest rise)
• Avoid excessive ventilation
04JUL2013 ACLS-BMS 11
12. Defibrillation
• Know your AED
• Universal steps:
1. Power ON
2. Attach electrode
pads
3. Analyze the rhythm
4. Shock (if advised)
12
Ernstl, Wikimedia Commons
15. Early
Defibrillation
With an AED
• Turn the AED on.
• Follow the AED prompts.
• Resume chest
compressions immediately
after the shock (minimize
interruptions).
04JUL2013 ACLS-BMS 15
22. Defibrillation
• Most frequent initial rhythm in
witnessed sudden cardiac arrest is
ventricular fibrillation (VF) or
pulseless ventricular tachycardia
(VT) which rapidly deteriorates into
VF
• The only effective treatment for VF
is electrical defibrillation
• Probability of successful
defibrillation diminishes rapidly over
time
• VF rapidly converts to asystole if
not treated
22
26. Airway
• Maintain airway patency
– Head tilt-chin lift/jaw thrust
– Oro- or nasopharyngeal airway
• Advanced airway management
– ETT
– Combitube
– LMA
Ignis, Wikimedia Commons 26
27. Breathing
• Assess adequacy of
oxygenation and
ventilation
• Provide
supplemental oxygen
• Confirm proper
airway placement
• Secure tube
27
28. Circulation
• Assess/monitor cardiac
rhythm
• Establish IV access
• Give medications as
appropriate for rhythm and
BP
• Fluid resuscitation
• Minimize interruption of
compressions to maximize
survival.
28
39. Basic
Rhythm
Analysis
• Rate – too fast or too slow?
• Rhythm – regular or
irregular?
• Is there a normal looking
QRS? Is it wide or narrow?
• Are P waves present?
• What is the relationship of
the P waves to the QRS
complex?
39
40. Rhythm Analysis
Lethal vs non-lethal?
Shockable vs. non-shockable? Too fast vs too slow?
Symptomatic vs. asymptomatic?
40
42. Non-
Lethal
Rhythms
• Too fast (tachycardias)
– Sinus
– Supraventricular (including a-
fib/flutter)
– Ventricular
• Too slow (bradycardias)
– Sinus
– Heart block (1°, 2°, 3°
AV block)
42
43. What is a
Symptomatic
Dysrhythmia?
• Any abnormal rhythm that produces signs or
symptoms of hypoperfusion
– Chest Pain/ischemic EKG changes
– Shortness of Breath
– Decreased level of consciousness
– Syncope/pre-syncope
– Hypotension
– Shock - decreased Uop, cool extremities, etc.
– Pulmonary Congestion/CHF
43
52. Ventricular Tachycardia
• Assume any wide complex tachycardia is VT
until proven otherwise
– SVT with aberrant conduction may also have wide
QRS complexes
• Attempt to establish the diagnosis
– Ischemia risk and VT go together
52
53. Treatment of VT
• If pulseless - follow VF algorithm
• If stable try anti-arrhythmics
– Amiodarone
– Lidocaine
– Procainamide?
• If patient has a pulse, but is unstable or not
responding to meds - shock
53
54. Treatment of VT
• Anti-arrhythmics are also pro-arrhythmic
• One antiarrhythmic may help, more than one
may harm
• Anti-arrhythmics can impair an already impaired
heart
• Electrical cardioversion should be the second
intervention of choice
54
55. 60yo diabetic man with chest pain
What is the rhythm?
What is the management?
Knutux, Wikimedia Commons 55
56. Normal Sinus Rhythm
• Regular rate and rhythm
• Normal P waves and QRS
• Evaluate for cause of chest pain and monitor for
change in rhythm
Knutux, Wikimedia Commons 56
57. 40 yo woman found down, pulseless and
apneic
What is the rhythm?
What is the management?
Masur, Wikimedia Commons 57
58. Pulseless Electrical Activity
• Any organized (or semi-organized) electrical
activity in a patient without a detectable pulse
• Non-perfusing
• Treat the patient NOT the monitor
• Find and treat the cause!!!!!
58
60. PEA
Atropine 1 mg IVP
if PEA is slow
Epinephrine 1 mg IVP
repeat every 3-5 minutes
Search for and Treat Causes
Secondary Survey
Primary Survey
60
61. Find and Treat the Cause
• Non-shockable rhythm
• The most effective treatment is to find and fix
the underlying problem
Rama, Wikimedia Commons
61
62. So what
causes
PEA?
• #1 cause of PEA in adults is
hypovolemia
• #1 cause in children is
hypoxia/respiratory arrest
• Other causes?
62
63. The H’s
and T’s
• Hypovolemia
• Hypoxia
• Hydrogen ion (acidosis)
• Hyper-/hypokalemia
• Hypothermia
• Hypoglycemia (rare)
• Toxins
• Tamponade
• Tension
pneumothorax
• Thrombosis
(coronary or
pulmonary)
• Trauma
63
65. 19yo man with palpitations
What is the rhythm?
What is the management?
Displaced, Wikimedia Commons
65
66. Supraventricular Tachycardia
• Rapid (usually 150-250 bpm) and regular
• P waves cannot be positively identified
• QRS narrow
Displaced, Wikimedia Commons
66
67. Treatment of Stable SVT
• Consider vagal maneuvers
– Carotid sinus massage
– Valsalva
– Eyeball massage
– Ice water to face
– Digital rectal exam
• Adenosine
– 6 mg, 12 mg, 12 mg
67
68. Treatment of Unstable SVT
• Electrical Cardioversion
• Cardioversion is not defibrillation
• Use defibrillator in “sync” mode
– prevents delivering energy in the wrong part of the
cardiac cycle (R on T phenomenon)
68
69. Electrical Cardioversion
• Energy level – somewhat controversial
• 100 J→200J→300J→360J
• Atrial flutter may convert with lower energy
– 50J
• For polymorphic VT – start with 200J
• The EP guys tend to start with 360J
69
70. Electrical Cardioversion
• Be prepared
– Patient on monitor, IV, Oxygen
– Suction ready and working
– Airway supplies ready
• Pre-medicate whenever possible
– Conscious sedation
– Electrical shocks are painful!
70
73. 56 yo woman with shortness of breath and
chest pain
What is the rhythm?
What is the management?
J. Heuser, Wikimedia Commons
73
74. Atrial fibrillation/flutter
• May be rapid
• Irregular (fib) or more regular (flutter)
• No P waves, narrow QRS
James Heilman, MD, Wikimedia Commons
J. Heuser, Wikimedia Commons
74
75. Atrial fibrillation/flutter
• Treatment based on patient’s clinical picture
– Unstable = Immediate electrical cardioversion
– Stable
• Control the rate
– Diltiazem
– Esmolol (not if EF < 40%)
– Digoxin
• Provide anticoagulation
• Treat the patient NOT the monitor!!!
75
76. 78yo man found down, pulseless and
apneic, unknown duration
What is the rhythm?
What is the management?
D Dinneen, Wikimedia Commons 76
77. Asystole
• Is it really asystole?
• Check lead and cable connections.
• Is everything turned on?
• Verify asystole in another lead.
• Maybe it is really fine v-fib?
D Dinneen, Wikimedia Commons 77
78. 68 yo woman with h/o hypertension
presents with dizziness
What is the rhythm?
What is the treatment?
Mysid, Wikimedia Commons 78
79. Sinus Bradycardia
• Slow and regular
• Normal P waves and QRS complexes
Mysid, Wikimedia Commons 79
80. Bradycardias
• Many possible causes
– Enhanced parasympathetic tone
– Increased ICP.
– Hypothyroidism
– Hypothermia
– Hyperkalemia
– Hypoglycemia
– Drug therapy
80
81. Bradycardias
• Treat only symptomatic bradycardias
– Ask if the bradycardia causing the symptoms
• Recognize the red flag bradycardias
– Second degree type II block
– Third degree block
81
83. Transcutaneous pacing
• Class I for all symptomatic bradycardias
• Always appropriate
• Doesn’t always work
• Technique
– Attach pacer pads
– Set a rate to 80 bpm
– Turn up the juice (amps) until you get capture
• Painful – may need sedation / analgesia
83
84. Transvenous Pacing
• Invasive
• Time-consuming to establish
• Skilled procedure
• Better long-term than transcutaneous
• May have better capture than transcutaneous
pacing
84
86. Know
When To
Stop
• With return of spontaneous
circulation
• No ROSC during or after 20
minutes of resuscitative
efforts
– Possible exceptions include
near-drowning, severe
hypothermia, known
reversible cause, some
overdoses
• Obvious signs of irreversible
death
86
87. Take
Home
Points
• Assess and manage at every step
before moving on to the next
step
• Rapid defibrillation is the ONLY
effective treatment for VF/VT
• Search for and treat the cause
• Treat the patient not the monitor
• Reassess frequently
• Minimize interruptions to chest
compressions
87
